Metastatic Epidural Spinal Cord Compression: Conventional Radiotherapy

Metastatic epidural spinal cord compression (MESCC) is an oncologic emergency requiring prompt treatment. MESCC is most commonly treated with radiotherapy with or without corticosteroids. Upfront decompressive surgery may benefit selected patients with good performance status and favorable survival prognosis. For radiotherapy, several dose-fractionation regimens are available ranging from a single fraction of 8–10 Gy, to multifraction long-course programs such as 20 Gy in 5 fractions, 30 Gy in 10 fractions, or 40 Gy in 20 fractions. The most appropriate regimen for an individual patient depends on the treatment goals and the patient’s expected lifespan. With respect to improvement of motor function specifically maintaining or regaining the ability to walk, a single fraction of 8 Gy is as effective as longer-course programs in the short-term. Longer-course regimens and dose-intensified short-course programs (with doses biologically equivalent to 30 Gy in 10 or 25 Gy in 5 fractions) provide better local control of MESCC than single-fraction radiotherapy and 20 Gy in 5 fractions. Since the risk of a recurrence of MESCC in the same area of the spine increases with lifespan, patients with a better survival prognosis appear better treated with longer-course or dose-intensified programs. Patients with a very favorable prognosis may benefit from dose-fractionation regimens with biologically effective doses higher than those achieved with 30 Gy in 10 fractions. Thus, for optimal personalization of radiotherapy in patients with MESCC, it is important to estimate a patient’s remaining lifespan, which is facilitated with corresponding survival scores.